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Check Handling Information APPENDIX I and Procedures 10/18 Page 17
What Relationship
If YES box is checked, answer how suspect is related to payee
Moved in last 60 days
Check YES or NO
Police report number
Number given to police report by local police department
MUST BE COMPLETED
Sign name
10 original payee signatures
Instructions For Preparation Of Lost Check Report
Date of Report Date affidavit is signed
Payee Name of person check is made payable to
Address of Payee Address as shown on warrant register, including City, State and ZIP
Home Phone Payee’s home telephone number
Work Phone Payee’s work telephone number
Cell Phone Payee’s cell phone number
Check Number Complete 8 digit check (warrant) number
Amount Entire amount of check, including cents
Date of Check
Date on check
Check Received
Check YES or NO
Where did the loss occur
Location of where check was lost
Other ID lost/missing Check YES or NO
If so, what type
List each piece of lost identification
Sign name
10 original payee signatures
TANF Transmittal 65